Saturday, April 27, 2013 -- Walkersville, WV / Stonewall Resort, 940 Resort Drive Roanoke, WV
General Lightburn Consol Energy 5k run & Wellness Walk & 1 mile Run
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RACE CONTACT: David J. Gallien (phone) 304-884-7811 (e-mail) d.gallien@crestviewmanor.com
Fee: $15.00 for each race if registered by April 15th, $20.00 thereafter
T-shirt guaranteed to pre-register runners, and as available on race day.
Payable to: Jane Lew Lions Club
Mail to:
Crestview Manor Nursing & Rehabilitation c/o David J. Gallien
P.O. Box 967, Jane Lew, WV 26378
NAME: Last__________________________________ First___________________________________
ADDRESS:_______________________________________________________________________________
CITY, STATE, ZIP_______________________________________________________________________
PHONE:_________________________________________________________________________________
Age:___________ Male_______ OR Female_____ // SHIRT SIZE: ___M ___L ___XL ___XXL
WHICH RACE(S) ARE YOU REGISTERING? 5K ___ ONE MILE ___ WELLNESS WALK _____
WAIVER:In consideration of the acceptance of the entry, I waive for myself, my heirs and assigns, all claims for damages which I might have against the race, its sponsors, or any other organizations, business or individual as a result of any and all injuries which might be received during the contest. I also release any photos that may involve myself.
SIGNATURE REQUIRED:________________________________________________________________
PARENTS MUST ALSO SIGN IF RUNNER IS UNDER 18 YEARS OF AGE
Parent/Legal Guardian:________________________________________________________________